Motor Symptoms Determining Disease-Specific Quality of Life in Parkinson's Patients
Year 2024,
, 1042 - 1055, 21.10.2024
Mustafa Ertuğrul Yaşa
,
Rıza Sonkaya
,
Buse Korkmaz
,
Büşra Nur Fındık
,
Şeyma Yaşar
,
Bilgin Öztürk
,
Ömer Karadaş
Abstract
With the ageing of societies and the increase in predisposing factors, a Parkinson pandemic is expected soon. This situation requires further research into the effects of Parkinson's disease. A Parkinson's pandemic, which is foreseen soon due to the aging of societies and the increase in predisposing factors, necessitates further research on the effects of this disease. This study was planned to investigate the motor symptoms that determine the disease-specific quality of life in a cohort of Parkinson's patients living in the Turkish community. The motor functions were evaluated with part 3 of the Unified Parkinson's Disease Rating Scale, upper extremity functions with the 9-hole peg test (9DPT), and quality of life with the Parkinson's Disease Quality of Life Scale-Short Form (PDQ-8). The motor symptoms that contributed the most to the disease-specific quality of life score was analyzed with backward linear regression analysis. The study was completed with 100 idiopathic Parkinson's patients (49 female, 51 male) with a mean age of 64.43±9.67 (years). 9DPT completion time (p<0.001), hand pronation/supination (p=0.027), freezing of gait (p=0.037), postural stability (p=0.023), and postural tremor in the hands (p=0.045) significantly affected the PDQ-8 score. This study revealed that impaired hand functions, freezing of gait and postural instability are the motor symptoms that determine the quality of life in Parkinson's patients. These findings will be significant in setting early rehabilitation goals.
References
- Adiguzel, A., Ozturk, U. ve Altinayar, S. (2020). Parkinson's Disease Profile–A 17-Year Patient Analysis. Dicle Tıp Dergisi, 47(3), 508-516. doi.org/10.5798/dicletip.757233.
- akbostanci, m. c., bayram, e., yilmaz, v., rzayev, s., özkan, s., tokcaer, a. b., . . . goetz, c. g. (2018). turkish standardization of movement disorders society unified parkinson's disease rating scale and unified dyskinesia rating scale. mov disord clin pract, 5(1), 54-59. doi:10.1002/mdc3.12556.
- Arslan, A. K., Yaşar, Ş., Çolak, C. ve Yoloğlu, S. (2018). wsspas: an interactive web application for sample size and power analysis with r using shiny. türkiye klinikleri biyoistatistik, 10(3), 224-246. doi:10.5336/biostatic.2018-62787
- Ben-Joseph, A., Marshall, C. R., Lees, A. J. ve Noyce, A. J. (2020). ethnic variation in the manifestation of parkinson's disease: a narrative review. j parkinsons dis, 10(1), 31-45. doi:10.3233/jpd-191763.
- Berganzo, K., Tijero, B., González-Eizaguirre, A., Somme, J., Lezcano, E., Gabilondo, I., . . . Gómez-Esteban, J. C. (2016). motor and non-motor symptoms of parkinson's disease and their impact on quality of life and on different clinical subgroups. neurologia, 31(9), 585-591. doi:10.1016/j.nrl.2014.10.010.
- Bock, M. A., Brown, E. G., Zhang, L. ve Tanner, C. (2022). association of motor and nonmotor symptoms with health-related quality of life in a large online cohort of people with parkinson disease. neurology, 98(22), e2194-e2203. doi:10.1212/wnl.0000000000200113.
- Braak, H., Del Tredici, K., Rüb, U., De Vos, R. A., Jansen Steur, E. N. ve Braak, E. (2003). staging of brain pathology related to sporadic parkinson's disease. neurobiol aging, 24(2), 197-211. doi:10.1016/s0197-4580(02)00065-9.
- Chapuis, S., Ouchchane, L., Metz, O., Gerbaud, L. ve Durif, F. (2005). impact of the motor complications of parkinson's disease on the quality of life. mov disord, 20(2), 224-230. doi.org/10.1002/mds.20279.
- Choi, Y. I., Song, C. S. ve Chun, B. Y. (2017). activities of daily living and manual hand dexterity in persons with idiopathic parkinson disease. j phys ther sci, 29(3), 457-460. doi:10.1589/jpts.29.457.
- De Lau, L. M. ve Breteler, M. M. (2006). epidemiology of parkinson's disease. lancet neurol, 5(6), 525-535. doi:10.1016/s1474-4422(06)70471-9.
- De Rijk, M. C., Breteler, M. M., Graveland, G. A., Ott, A., Grobbee, D. E., Van Der Meché, F. G. ve Hofman, A. (1995). prevalence of parkinson's disease in the elderly: the rotterdam study. neurology, 45(12), 2143-2146. doi:10.1212/wnl.45.12.2143.
- Dorsey, E. R., Sherer, T., Okun, M. S. ve Bloem, B. R. (2018). the emerging evidence of the parkinson pandemic. j parkinsons dis, 8(s1), 3-8. doi:10.3233/jpd-181474.
- Doucet, B. M., Blanchard, M. ve Bienvenu, F. (2021). occupational performance and hand function in people with parkinson’s disease after participation in lee silverman voice treatment (lsvt) big®. the american journal of occupational therapy, 75(6), 7506205010. doi.org/10.5014/ajot.2021.042101.
- Earhart, G. M., Cavanaugh, J. T., Ellis, T., Ford, M. P., Foreman, K. B. ve Dibble, L. (2011). the 9-hole peg test of upper extremity function: average values, test-retest reliability, and factors contributing to performance in people with parkinson disease. j neurol phys ther, 35(4), 157-163. doi:10.1097/npt.0b013e318235da08.
- Gao, C., Liu, J., Tan, Y. ve Chen, S. (2020). freezing of gait in parkinson’s disease: pathophysiology, risk factors and treatments. transl neurodegener, 9, 1-22. doi.org/10.1186/s40035-020-00191-5.
- García, D. S., De Deus Fonticoba, T., Castro, E. S., Borrué, C., Mata, M., Vila, B. S., . . . Vela, L. (2019). non-motor symptoms burden, mood, and gait problems are the most significant factors contributing to a poor quality of life in non-demented parkinson's disease patients: results from the coppadis study cohort. parkinsonism ve related disorders, 66, 151-157. doi.org/10.1016/j.parkreldis.2019.07.031.
- Goetz, C. G., Poewe, W., Rascol, O., Sampaio, C., Stebbins, G. T., Counsell, C., . . . Seidl, L. (2004). movement disorder society task force report on the hoehn and yahr staging scale: status and recommendations. mov disord, 19(9), 1020-1028. doi:10.1002/mds.20213.
- Jenkinson, C., Fitzpatrick, R., Peto, V., Greenhall, R. ve Hyman, N. (1997). the pdq-8: development and validation of a short-form parkinson's disease questionnaire. psychology and health, 12(6), 805-814. doi.org/10.1080/08870449708406741.
- Kahraman, T., Genç, A., Söke, F., Göz, E., Çolakoğlu, B. D. ve Keskįnoğlu, P. (2018). validity and reliability of the turkish version of the 8-item parkinson's disease questionnaire. noro psikiyatr ars, 55(4), 337-340. doi:10.5152/npa.2017.19343.
- Keskinoglu, P., Ucku, R., Yener, G., Yaka, E., Kurt, P. ve Tunca, Z. (2009). reliability and validity of revised turkish version of mini mental state examination (rmmse-t) in community-dwelling educated and uneducated elderly. int j geriatr psychiatry, 24(11), 1242-1250. doi:10.1002/gps.2252.
- Kilinc, B., Cetisli-Korkmaz, N., Bir, L. S., Marangoz, A. D. ve Senol, H. (2023). the quality of life in individuals with parkinson’s disease: is it related to functionality and tremor severity? a cross-sectional study. physiotherapy theory and practice, 29, 1-10. doi: 10.1080/09593985.2023.2236691.
- Kurihara, K., Nakagawa, R., Ishido, M., Yoshinaga, Y., Watanabe, J., Hayashi, Y., . . . Tsuboi, Y. (2020). impact of motor and nonmotor symptoms in parkinson disease for the quality of life: the japanese quality-of-life survey of parkinson disease (jaqpad) study. j neurol sci, 15;419, 117172. doi:10.1016/j.jns.2020.117172.
- Mcsp, I. C. B. ve Dipcot, J. A. (2003). a comparison of dominant and non-dominant hand function in both right-and left-handed individuals using the southampton hand assessment procedure (shap). the british journal of hand therapy, 8(1), 4-10. doi.org/10.1177/175899830300800101.
- Moore, O., Peretz, C. ve Giladi, N. (2007). freezing of gait affects quality of life of peoples with parkinson's disease beyond its relationships with mobility and gait. mov disord, 22(15), 2192-2195. doi.org/10.1002/mds.21659.
- Perez-Lloret, S., Negre-Pages, L., Damier, P., Delval, A., Derkinderen, P., Destée, A., . . . Rascol, O. (2014). prevalence, determinants, and effect on quality of life of freezing of gait in parkinson disease. jama neurology, 71(7), 884-890. doi:10.1001/jamaneurol.2014.753.
- Postuma, R. B., Berg, D., Stern, M., Poewe, W., Olanow, C. W., Oertel, W., . . . Deuschl, G. (2015). mds clinical diagnostic criteria for parkinson's disease. mov disord, 30(12), 1591-1601. doi:10.1002/mds.26424.
- Rahman, S., Griffin, H. J., Quinn, N. P. ve Jahanshahi, M. (2008). quality of life in parkinson's disease: the relative importance of the symptoms. mov disord, 23(10), 1428-1434. doi: 10.1002/mds.21667.
- Schrag, A., Jahanshahi, M. ve Quinn, N. (2000). what contributes to quality of life in patients with parkinson's disease? journal of neurology, neurosurgery, and psychiatry, 69(3), 308-312. doi: 10.1136/jnnp.69.3.308.
- Soares, L. T., Pereira, A. J. F., Magno, L. D. P., Figueiras, H. D. M. ve Sobral, L. L. (2014). balance, gait and quality of life in parkinson's disease: effects of whole body vibration treatment. fisioterapia em movimento, 27, 261-270. doi: http://dx.doi.org.10.1590/0103-5150.027.002.ao11.
- Taghizadeh, G., Azad, A., Kashefi, S., Fallah, S. ve Daneshjoo, F. (2018). the effect of sensory-motor training on hand and upper extremity sensory and motor function in patients with idiopathic parkinson disease. journal of hand therapy, 31(4), 486-493. doi: 10.1016/j.jht.2017.08.001.
- Vanbellingen, T., Nyffeler, T., Nigg, J., Janssens, J., Hoppe, J., Nef, T., . . . Bohlhalter, S. (2017). home based training for dexterity in parkinson's disease: a randomized controlled trial. parkinsonism ve related disorders, 41, 92-98. doi: 10.1016/j.parkreldis.2017.05.021.
- Von Campenhausen, S., Bornschein, B., Wick, R., Bötzel, K., Sampaio, C., Poewe, W., . . . Dodel, R. (2005). prevalence and incidence of parkinson's disease in europe. eur neuropsychopharmacol, 15(4), 473-490. doi:10.1016/j.euroneuro.2005.04.007.
- Walton, C. C., Shine, J. M., Hall, J. M., O’callaghan, C., Mowszowski, L., Gilat, M., . . . Lewis, S. J. (2015). the major impact of freezing of gait on quality of life in parkinson’s disease. journal of neurology, 262, 108-115. doi: 10.1007/s00415-014-7524-3.
- Wong-Yu, I. S. K., Ren, L. ve Mak, M. K. Y. (2022). impaired hand function and its association with self-perceived hand functional ability and quality of life in parkinson disease. am j phys med rehabil, 101(9), 843-849. doi:10.1097/phm.0000000000001923.
- World Health Organisation. (1995). the world health organization quality of life assessment (WHO/QOL): position paper from the world health organization. Soc Sci Med, 41, 1403-1409. doi: 10.1016/0277-9536(95)00112-k.
PARKİNSON HASTALARINDA HASTALIĞA ÖZGÜ YAŞAM KALİTESİNİ BELİRLEYEN MOTOR SEMPTOMLAR
Year 2024,
, 1042 - 1055, 21.10.2024
Mustafa Ertuğrul Yaşa
,
Rıza Sonkaya
,
Buse Korkmaz
,
Büşra Nur Fındık
,
Şeyma Yaşar
,
Bilgin Öztürk
,
Ömer Karadaş
Abstract
Toplumların yaşlanması ve hazırlayıcı faktörlerin artmasıyla yakın gelecekte bir Parkinson pandemisi beklenmektedir. Bu durum Parkinson hastalığının etkilerini daha çok araştırmayı gerekli kılmaktadır. Bu çalışma Türk toplumunda yaşayan Parkinson hastalarından oluşmuş bir grup üzerinde hastalığa özgü yaşam kalitesini belirleyen motor semptomların araştırılması amacıyla planlanmıştır. Hastaların motor fonksiyonları Birleşik Parkinson Hastalığı Derecelendirme Ölçeği’nin 3. Bölümü ile, üst ekstremite fonksiyonları 9-delikli peg test (9DPT) ile, yaşam kalitesi Parkinson Hastalığı Yaşam Kalitesi Ölçeği – Kısa Form (PDQ-8) ile değerlendirildi. Hangi motor semptom değişkeninin yaşam kalitesi puanına en çok katkı sağladığı geriye doğru doğrusal regresyon analizi ile incelendi. Çalışma ortalama yaşları 64,43±9,67 (yıl) olan 100 idiopatik Parkinson hastası (49 kadın, 51 erkek) ile tamamlandı. 9DPT tamamlama süresinin (p<0.001), el pronasyon/supinasyon (p=0.027), yürürken donma (p=0.037), postüral stabilite (p=0.023) ve ellerde postüral tremor (p=0.045) skorlarının PDQ-8 skorunu anlamlı düzeyde etkilediği bulundu. Bu çalışma Parkinson hastalarında özellikle el fonksiyonunun, yürüyüş becerisinin ve postüral kontrol fonksiyonunun yaşam kalitesini belirleyen motor semptomlar olduğunu ortaya koymuştur. Erken dönem rehabilitasyon hedefleri belirlenirken bu sonuçların da göz önünde bulundurulması yararlı olacaktır.
Ethical Statement
Çalışma için Sağlık Bilimleri Üniversitesi Gülhane Bilimsel Araştırmalar Etik Kurulu'nun 21/10/2021 tarihli toplantısında 2021-335 karar numarası ile etik kurul onayı alındı. Çalışma kapsamında yapılan tüm prosedürler Helsinki Deklarasyonuna uygun olarak gerçekleştirildi. Çalışmaya başlamadan önce katılımcılara çalışma hakkında bilgi verilmiş ve yazılı onamları alındı.
Supporting Institution
Çalışmamız herhangi bir kurum tarafından desteklenmemiştir
References
- Adiguzel, A., Ozturk, U. ve Altinayar, S. (2020). Parkinson's Disease Profile–A 17-Year Patient Analysis. Dicle Tıp Dergisi, 47(3), 508-516. doi.org/10.5798/dicletip.757233.
- akbostanci, m. c., bayram, e., yilmaz, v., rzayev, s., özkan, s., tokcaer, a. b., . . . goetz, c. g. (2018). turkish standardization of movement disorders society unified parkinson's disease rating scale and unified dyskinesia rating scale. mov disord clin pract, 5(1), 54-59. doi:10.1002/mdc3.12556.
- Arslan, A. K., Yaşar, Ş., Çolak, C. ve Yoloğlu, S. (2018). wsspas: an interactive web application for sample size and power analysis with r using shiny. türkiye klinikleri biyoistatistik, 10(3), 224-246. doi:10.5336/biostatic.2018-62787
- Ben-Joseph, A., Marshall, C. R., Lees, A. J. ve Noyce, A. J. (2020). ethnic variation in the manifestation of parkinson's disease: a narrative review. j parkinsons dis, 10(1), 31-45. doi:10.3233/jpd-191763.
- Berganzo, K., Tijero, B., González-Eizaguirre, A., Somme, J., Lezcano, E., Gabilondo, I., . . . Gómez-Esteban, J. C. (2016). motor and non-motor symptoms of parkinson's disease and their impact on quality of life and on different clinical subgroups. neurologia, 31(9), 585-591. doi:10.1016/j.nrl.2014.10.010.
- Bock, M. A., Brown, E. G., Zhang, L. ve Tanner, C. (2022). association of motor and nonmotor symptoms with health-related quality of life in a large online cohort of people with parkinson disease. neurology, 98(22), e2194-e2203. doi:10.1212/wnl.0000000000200113.
- Braak, H., Del Tredici, K., Rüb, U., De Vos, R. A., Jansen Steur, E. N. ve Braak, E. (2003). staging of brain pathology related to sporadic parkinson's disease. neurobiol aging, 24(2), 197-211. doi:10.1016/s0197-4580(02)00065-9.
- Chapuis, S., Ouchchane, L., Metz, O., Gerbaud, L. ve Durif, F. (2005). impact of the motor complications of parkinson's disease on the quality of life. mov disord, 20(2), 224-230. doi.org/10.1002/mds.20279.
- Choi, Y. I., Song, C. S. ve Chun, B. Y. (2017). activities of daily living and manual hand dexterity in persons with idiopathic parkinson disease. j phys ther sci, 29(3), 457-460. doi:10.1589/jpts.29.457.
- De Lau, L. M. ve Breteler, M. M. (2006). epidemiology of parkinson's disease. lancet neurol, 5(6), 525-535. doi:10.1016/s1474-4422(06)70471-9.
- De Rijk, M. C., Breteler, M. M., Graveland, G. A., Ott, A., Grobbee, D. E., Van Der Meché, F. G. ve Hofman, A. (1995). prevalence of parkinson's disease in the elderly: the rotterdam study. neurology, 45(12), 2143-2146. doi:10.1212/wnl.45.12.2143.
- Dorsey, E. R., Sherer, T., Okun, M. S. ve Bloem, B. R. (2018). the emerging evidence of the parkinson pandemic. j parkinsons dis, 8(s1), 3-8. doi:10.3233/jpd-181474.
- Doucet, B. M., Blanchard, M. ve Bienvenu, F. (2021). occupational performance and hand function in people with parkinson’s disease after participation in lee silverman voice treatment (lsvt) big®. the american journal of occupational therapy, 75(6), 7506205010. doi.org/10.5014/ajot.2021.042101.
- Earhart, G. M., Cavanaugh, J. T., Ellis, T., Ford, M. P., Foreman, K. B. ve Dibble, L. (2011). the 9-hole peg test of upper extremity function: average values, test-retest reliability, and factors contributing to performance in people with parkinson disease. j neurol phys ther, 35(4), 157-163. doi:10.1097/npt.0b013e318235da08.
- Gao, C., Liu, J., Tan, Y. ve Chen, S. (2020). freezing of gait in parkinson’s disease: pathophysiology, risk factors and treatments. transl neurodegener, 9, 1-22. doi.org/10.1186/s40035-020-00191-5.
- García, D. S., De Deus Fonticoba, T., Castro, E. S., Borrué, C., Mata, M., Vila, B. S., . . . Vela, L. (2019). non-motor symptoms burden, mood, and gait problems are the most significant factors contributing to a poor quality of life in non-demented parkinson's disease patients: results from the coppadis study cohort. parkinsonism ve related disorders, 66, 151-157. doi.org/10.1016/j.parkreldis.2019.07.031.
- Goetz, C. G., Poewe, W., Rascol, O., Sampaio, C., Stebbins, G. T., Counsell, C., . . . Seidl, L. (2004). movement disorder society task force report on the hoehn and yahr staging scale: status and recommendations. mov disord, 19(9), 1020-1028. doi:10.1002/mds.20213.
- Jenkinson, C., Fitzpatrick, R., Peto, V., Greenhall, R. ve Hyman, N. (1997). the pdq-8: development and validation of a short-form parkinson's disease questionnaire. psychology and health, 12(6), 805-814. doi.org/10.1080/08870449708406741.
- Kahraman, T., Genç, A., Söke, F., Göz, E., Çolakoğlu, B. D. ve Keskįnoğlu, P. (2018). validity and reliability of the turkish version of the 8-item parkinson's disease questionnaire. noro psikiyatr ars, 55(4), 337-340. doi:10.5152/npa.2017.19343.
- Keskinoglu, P., Ucku, R., Yener, G., Yaka, E., Kurt, P. ve Tunca, Z. (2009). reliability and validity of revised turkish version of mini mental state examination (rmmse-t) in community-dwelling educated and uneducated elderly. int j geriatr psychiatry, 24(11), 1242-1250. doi:10.1002/gps.2252.
- Kilinc, B., Cetisli-Korkmaz, N., Bir, L. S., Marangoz, A. D. ve Senol, H. (2023). the quality of life in individuals with parkinson’s disease: is it related to functionality and tremor severity? a cross-sectional study. physiotherapy theory and practice, 29, 1-10. doi: 10.1080/09593985.2023.2236691.
- Kurihara, K., Nakagawa, R., Ishido, M., Yoshinaga, Y., Watanabe, J., Hayashi, Y., . . . Tsuboi, Y. (2020). impact of motor and nonmotor symptoms in parkinson disease for the quality of life: the japanese quality-of-life survey of parkinson disease (jaqpad) study. j neurol sci, 15;419, 117172. doi:10.1016/j.jns.2020.117172.
- Mcsp, I. C. B. ve Dipcot, J. A. (2003). a comparison of dominant and non-dominant hand function in both right-and left-handed individuals using the southampton hand assessment procedure (shap). the british journal of hand therapy, 8(1), 4-10. doi.org/10.1177/175899830300800101.
- Moore, O., Peretz, C. ve Giladi, N. (2007). freezing of gait affects quality of life of peoples with parkinson's disease beyond its relationships with mobility and gait. mov disord, 22(15), 2192-2195. doi.org/10.1002/mds.21659.
- Perez-Lloret, S., Negre-Pages, L., Damier, P., Delval, A., Derkinderen, P., Destée, A., . . . Rascol, O. (2014). prevalence, determinants, and effect on quality of life of freezing of gait in parkinson disease. jama neurology, 71(7), 884-890. doi:10.1001/jamaneurol.2014.753.
- Postuma, R. B., Berg, D., Stern, M., Poewe, W., Olanow, C. W., Oertel, W., . . . Deuschl, G. (2015). mds clinical diagnostic criteria for parkinson's disease. mov disord, 30(12), 1591-1601. doi:10.1002/mds.26424.
- Rahman, S., Griffin, H. J., Quinn, N. P. ve Jahanshahi, M. (2008). quality of life in parkinson's disease: the relative importance of the symptoms. mov disord, 23(10), 1428-1434. doi: 10.1002/mds.21667.
- Schrag, A., Jahanshahi, M. ve Quinn, N. (2000). what contributes to quality of life in patients with parkinson's disease? journal of neurology, neurosurgery, and psychiatry, 69(3), 308-312. doi: 10.1136/jnnp.69.3.308.
- Soares, L. T., Pereira, A. J. F., Magno, L. D. P., Figueiras, H. D. M. ve Sobral, L. L. (2014). balance, gait and quality of life in parkinson's disease: effects of whole body vibration treatment. fisioterapia em movimento, 27, 261-270. doi: http://dx.doi.org.10.1590/0103-5150.027.002.ao11.
- Taghizadeh, G., Azad, A., Kashefi, S., Fallah, S. ve Daneshjoo, F. (2018). the effect of sensory-motor training on hand and upper extremity sensory and motor function in patients with idiopathic parkinson disease. journal of hand therapy, 31(4), 486-493. doi: 10.1016/j.jht.2017.08.001.
- Vanbellingen, T., Nyffeler, T., Nigg, J., Janssens, J., Hoppe, J., Nef, T., . . . Bohlhalter, S. (2017). home based training for dexterity in parkinson's disease: a randomized controlled trial. parkinsonism ve related disorders, 41, 92-98. doi: 10.1016/j.parkreldis.2017.05.021.
- Von Campenhausen, S., Bornschein, B., Wick, R., Bötzel, K., Sampaio, C., Poewe, W., . . . Dodel, R. (2005). prevalence and incidence of parkinson's disease in europe. eur neuropsychopharmacol, 15(4), 473-490. doi:10.1016/j.euroneuro.2005.04.007.
- Walton, C. C., Shine, J. M., Hall, J. M., O’callaghan, C., Mowszowski, L., Gilat, M., . . . Lewis, S. J. (2015). the major impact of freezing of gait on quality of life in parkinson’s disease. journal of neurology, 262, 108-115. doi: 10.1007/s00415-014-7524-3.
- Wong-Yu, I. S. K., Ren, L. ve Mak, M. K. Y. (2022). impaired hand function and its association with self-perceived hand functional ability and quality of life in parkinson disease. am j phys med rehabil, 101(9), 843-849. doi:10.1097/phm.0000000000001923.
- World Health Organisation. (1995). the world health organization quality of life assessment (WHO/QOL): position paper from the world health organization. Soc Sci Med, 41, 1403-1409. doi: 10.1016/0277-9536(95)00112-k.